Healthcare Transformation: A New Claims Processing Platform

Experience and an accelerated approach help a leading dental payer advance and implement a critical transformation initiative

West Monroe helped a dental payer refine, validate, and then implement a new claims processing platform and processes - and by doing so, improve efficiency, increase member self-service capabilities, and position the company for future growth and acquisitions.

The client administers dental benefit programs for more than 12 million members in 24 states plus the District of Columbia, making it one of the largest dental benefits companies in the United States.

When a leading dental benefits company wanted to make sure it was on course to achieve aggressive business goals, it turned to West Monroe Partners. West Monroe Partners helped the company refine, validate, and then implement a new claims processing platform and processes—and by doing so, improve efficiency, increase member self-service capabilities, and position the company for future growth and acquisitions.

A foundation for its future operating model.The client’s Government and Commercial business units operated almost entirely independently and used disparate core membership, provider, and claims processing systems. In early 2008, the company initiated a business transformation initiative that would replace the two business units’ separate legacy claims processing systems. The client wanted a foundation upon which it could design and build its future operating model. Implementing a single system would allow the company to drive toward key business objectives:

Improve operational portability

Increase electronic and self-service capabilities

Increase efficiency and optimize the supply chain

Grow market share through additional sales opportunities

Prepare effectively for healthcare reform and for capturing opportunities in a changing environment

Extend into new products and lines of business effectively

Improve business intelligence/analytics capabilities

Enhance its brand

Position the enterprise for future mergers or acquisition

This system selection and implementation project would require enterprise-wide process and system standardization and redesign across multiple business units in an aggressive time frame of approximately two years.

Offer guidance for the tactical execution of merging business operations

An accelerated approach.Given the emphasis on speed to implementation, West Monroe Partners and the client chose to use an accelerated, process-driven approach that emphasized the adoption of the new system’s native functionality wherever possible. System enhancements were designated as the option of last resort. Using a custom blend of packaged software implementation, software development, and business process engineering methodologies, the program team developed a repeatable approach and work plan to drive process standardization across the client’s business units and limit system modifications. Execution of this plan required focused collaboration among West Monroe Partners and client team members, while remaining nimble to adapt to necessary changes. The work plan comprised five phases.

Phase 1: Development of the target business model.To facilitate the client’s urgent need to envision its future operating model, West Monroe Partners conducted a Target Business Model (TBM) exercise designed to capture current-state and target future-state business processes. The project team organized the TBM exercise around West Monroe Partners’ Healthcare Process Classification, a breakdown of the standard functional areas and associated processes for the healthcare industry.

To capture current-state processes and design standard future-state processes, the team conducted one TBM session per function over a period of six weeks.

Phase 2: Requirements gathering, gap analysis & future state design.The TBM effort confirmed that the client’s business requirements were not fully understood, and that its future-state design needed further analysis. For the next several months, West Monroe process architects and client business analysts worked with the client business leads to understand their processes and their business requirements, some of which were contractually mandated. Once the project team catalogued this information, the requirements were tested in the new system to identify gaps where the system did not meet business needs. West Monroe worked with business owners to analyze these gaps and elect whether to change the system or adapt processes so they would work in coordination with the existing software.

Phase 3: Development of core claims system and reporting.Where system changes were deemed necessary, West Monroe Partners’ business analysts developed use cases detailing those changes. This ensured that the requirements and processes needed to sustain business operations were built and incorporated correctly. With system changes identified, West Monroe used the future operating model (developed during the TBM exercise) to create future-state processes and detail how each of the clients’ functional areas would operate with the new system in place. This stage of work also involved business intelligence and reporting, extracts and interfaces, and a web portal, as well as associated integration with external systems that connect to the core claims system.

Phase 4: Validation of the business model (VBM).West Monroe Partners then walked through the future-state solutions designed for the client. The project team created test activities and scenarios to validate the newly designed processes and system enhancements for “functional acceptance” by using a “model office” to simulate real-life use. By having business users validate end-to-end transaction processing, the project team was able to accelerate user acceptance and make minor adjustments prior to the “go-live” date to produce a system that would process claims effectively, as the client desired.

Phase 5: Claims platform transformation.Finally, with all future-state processes and system changes finalized, the program team (comprised of client and West Monroe team members) launched the new practices and procedures and implemented the new claims platform for more than 10 million members.

Providing program governance and structure.The impact and aggressive time frame of this project left little room for delay. It was imperative to establish a governing body to manage project resources, communications, time lines, and reporting to key stakeholders. To do so, West Monroe Partners established a program management office (PMO) that provided program leadership, methodology, tools, and templates to support program-wide status reporting, timely decision-making, risk mitigation, and execution of quarterly program quality reviews.

Driving adoption through change management.An integral part the project’s success was incorporating an organizational change management function that provided the program with methodology, tools, and proactive direction for the change effort across internal and external stakeholder groups.

West Monroe Partners managed the work executed by the client’s corporate communications team and human resources groups in support of formal communications, job impact assessments, stakeholder management, and knowledge transfer. The result was a high level of understanding and engagement across internal and external constituents, allowing the client to absorb changes resulting from the “go-live” process and accelerate towards the benefits of the new system.

Objectives achieved, transformation on course.By working with West Monroe Partners to implement a new claims processing platform and processes, the client has taken significant steps toward transforming its operations and realizing its business objectives. Results to date include:

Reducing core business processes by 40 percent via standardization

Increasing auto-adjudication across the enterprise at the rate of approximately 1.2 million claims and prior authorizations per month

Reducing headcount through implementation of optical character recognition (OCR) and off-shore OCR repair and key from image (KFI)

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